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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 10/12/2024
Date Signed: 10/12/2024 05:03:29 PM

Document Has Been Signed on 10/12/2024 05:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME:SKYHILL QUALITY LIVINGFACILITY NUMBER:
197608910
ADMINISTRATOR/
DIRECTOR:		ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:3919 W VICTORY BLVDTELEPHONE:
(818) 558-5971
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 6CENSUS: 6DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Rowena BacucangTIME VISIT/
INSPECTION COMPLETED:
02:59 PM
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On 10/12/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Rowena Bacucang and explained the purpose of today’s visit. Bucucan contacted administrator Tina Arutyunyan by telephone who was not able to be present for this visit. The facility is licensed to operate for six (6) non-ambulatory of which (1) may be bedridden. The facility is approved for (4) hospice residents. Currently, the facility has (4) residents in hospice care.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, an outside patio area, and garage used for storage.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 109.0-degree F. A comfortable temperature of 73 degree was maintained in the facility.

LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was maintained in order. The facility has conducted a disaster drill on 07/14/24. A landline telephone was in working condition. A review of staff CPR/First Aid training is current.
Evaluation Report Continues LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/12/2024 05:03 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/12/2024 at 02:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: SKYHILL QUALITY LIVING
FACILITY NUMBER: 197608910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed loose faucet in rear bathroom and a loose toilet flusher in front bathroom. This which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Licensee will ensure that all bathroom fixtures shall be in good repair. Proof of correction is for licensee to replace or repair faucet and toilet flusher must be sent by due date. Proof of correction with photos must be sent to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. LPA identified (1) out of (6) residents is diagnosed with dementia and (4) residents are on hospice care. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2024
Plan of Correction
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Licensee will ensure include a night shift "awake" staff. Proof of correction is for licensee to submit an updated LIC 500 to include proof of night staff on duty between 7pm- 7am. POC must be sent by due date. Proof of correction with photos must be sent to ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: SKYHILL QUALITY LIVING
FACILITY NUMBER: 197608910
VISIT DATE: 10/12/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. The facility is current on Community Care Licensing annual dues.

An audit of residents #1-#6 (R1-R6) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. The facility has the current administrator's certification on file for Akop Ekmyan #7001640740 exp. 07/31/25.

DEFICIENCIES:
  • Resident room #4 is missing a window screen.
  • Resident #4 is diagnosed with Dementia and (4) residents on hospice with no night shift "awake" staff.
  • (2) stove burners and oven non-operable.
  • Kitchen walls, ceiling and exhaust fan full of grease is unsanitary.
  • Bathroom faucet and toilet flusher loose/not tight fitting require repair.


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D).

An exit interview conducted with Rowen Bucucang, a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/12/2024 05:03 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/12/2024 at 02:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: SKYHILL QUALITY LIVING
FACILITY NUMBER: 197608910

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified resident room #4 is missing a window screen. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Licensee will ensure that all windows have screens and are maintained in good repair. Proof of correction is for licensee to purchase screen or make repairs must be sent by due date. Proof of correction with photos must be sent to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87303(a)(1)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatin, the licensee did not comply with the section cited above. LPA identified (2) range burners and oven non operarable. LPA identified grease stains on kitchen wall and ceiling and over range exhaust fan. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2024
Plan of Correction
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Licensee will ensure all kitchen equipments are in working conditon and kitchen area is clean and sanitary. Proof of correction is for licensee to replace or purchase stove and have perform deep cleaning of walls and ceiling. Proof of correction with photos must be sent to ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024


LIC809 (FAS) - (06/04)
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